We report a rare case of duodenal carcinoma treated by surgery. A 70-year-old level woman presented blacky stool and vomiting. Esophagogastroduodenoscopy revealed stenosis of duodenum, and she was referred to our hospital for further examination and treatment. Abdominal computed tomography scanning showed a mass that was located in the 2nd portion of the duodenum. Pathological examination by endoscopic biopsy revealed adenocarcinoma. Pancreatoduodenectomy was performed and histological diagnosis was primary duodenal adenocarcinoma. Although we added adjuvant chemotherapy by gemcitabine, metastatic lesions were found in the lung, liver and peritonium 13 months after surgery.

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A 17-year-old man was seen at the medical clinic because of suffering from hematochezia for 7 years. Colonoscopy showed a white granular tumor occuping almost all round of the anal verge. Biopsy revealed serrated adenoma (SA). Abdominal CT and PET revealed no metastatic lesions. CEA and CA19-9 were negative. The SA was localized on lower rectum, so transanal submucosal dissection was performed. Pathologocal diagnosis was SA with moderate grade dysplasia in the mucosal layer. The tumor margin was enough. The patient was discharge 8 days after the surgery. Transanal resection of juvenile SA on the lower rectum, which was very rare, was performed, considering the function of the anus.

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A 75-year-old man was admitted to our hospital for further investigation of multiple early gastric cancers. Three cancerous lesions were found by gastrointestinal endoscopy and biopsies confirmed well differentiated tubular adenocarcinoma. Endoscopic ultrasonography (EUS) findings suggested carcinoma of the upper gastric body invading sm2 or sm3; thus, we performed laparoscopy-assisted total gastrectomy. Interestingly, the pathological diagnosis was multiple early gastric cancer with diffuse cystic malformation (DCM) . Contrary to the preoperative diagnosis based on the EUS findings, the carcinoma of the upper gastric body existed in the mucosal layer (m) . The submucosal multiple cysts made assessing the tumor depth of invasion difficult by EUS in this case of gastric cancer with DCM. Thus, treatment should be decided only after confirming the tumor depth pathologically with endoscopic submucosal dissection.

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A 75-year-old man who had a history of rupture of primary liver cancer was admitted to Kanmon Medical Center with severe anemia (Hb 3. 0 g/dl). A bleeding ulcerative tumor (ulcerated type with clear margin (Type2) ) was found by esophagogastroduodenoscopic examination. The tumor was located from duodenal bulb to duodenal 2nd portion. Direct invasion of the primary liver cancer to the duodenum was suspected by specimen biopsy and abdominal CT. Invasion of the primary liver cancer to the duodenum is relatively rare (1%) among metastasis of primary liver cancer to other organs. In this paper, we report a rare case of this primary liver cancer invading into duodenum directly.

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Impalement injury is a relatively rare cause of blunt injury. We report the case of a patient with an impalement injury to the rectum. A 37-year-old man was accidentally stabbed in his anus with a stick of a bamboo rake that was standing against a truck when he jumped from the truck bed. He removed it himself and visited our hospital because of anal pain and bleeding. There was a wound to the posterior side of the anus. Abdominal CT scan showed free air and hematoma in the right pararectal space. Gastrografin enema study showed leakage of X-ray contrast agent from the right wall of the lower rectum. An emergency laparotomy was performed under the clinical diagnosis of traumatic rectal perforation. The laparotomy revealed a blood clot, stool, pubic hair and pieces of clothing in the right pararectal space. A perforation 1. 8 cm in diameter was found in the lower rectal right wall. The perforation was primary sutured and a colostomy was formed with the sigmoid colon, following transanal suture repair of the laceration of the anal mucosa. The postoperative course was uneventful and the patient was discharged on the 25^th day. The colostomy was closed 8 months after the operation. In perineal impalement injury, prompt assessment of the extent of internal organ injuries and consequent appropriate treatment are most important. Furthermore, the presence of foreign substances in the abdominal cavity should be investigated.

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